1. Department of Obstetric & Gynecology
Benign ovarian Tumors
Dr. Fayez Khatib
Department of Obstetric & Gynecology
SZMC

2. Normal adult ovary

3. Normal adult ovary
Ovaries are normally not palpable in pre-menarche, and after the menopause
In the reproductive age group ovaries are palpable in the lean pts.
Ovarian size of different age groups
Premenopause x 2 x 1.5 cm
Early menopause 1 – 2 yrs x 1.5x0.5cm
Late menopause 2-5yrs x0.75x0.5cm

4. Normal adult ovary Variation in dimensions can result from
Endogenous hormonal production(varies with age and menstrual cycle)
Exogenous substances, including OCs, GnRH agonists or ovulation-inducing medication, may affect size

5. Lifetime Risk of ovarian neoplasm
A woman has 5–10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm
13–21% of these will be found to be have an ovarian malignancy
Differential diagnosis of the adnexal masses varies considerably with the age of the patients.
In pre-menarchal girls and post-menopausal women adnexal mass should be considered highly abnormal – requires immediate investigation.
In menstruating patients differential diagnosis is varied.

6. Normal adult ovary

8. Classification Neoplasms derived from the surface epithelium- 65-80%
• Neoplasms derived from germ cells-10-15%
• Neoplasms derived from specialized gonadal stroma- 5-10%
• Neoplasms metastatic to the ovary-5%

9. Specialized gonadal stromal
Ovarian Neoplasm By Age
Type
Epithelial
Germ cell
Specialized gonadal stromal
Metastatic

10. Specialized gonadal stromal
Ovarian Neoplasm By Age
Type
<20y
Epithelial
29%
Germ cell
59%
Specialized gonadal stromal 8%
Metastatic 4%

11. Specialized gonadal stromal
Ovarian Neoplasm By Age
Type
20-50y
Epithelial
71%
Germ cell
14%
Specialized gonadal stromal 5%
Metastatic
10%

12. Specialized gonadal stromal
Ovarian Neoplasm By Age
Type
>50y
Epithelial
81%
Germ cell 6%
Specialized gonadal stromal 4%
Metastatic 9%

13. Types of Ovarian Tumors
OVARIAN MASSES
FUNCTIONAL
INFLAMMATORY
NEOPLASTIC
OTHERS
BENIGN
BORDERLINE
MALIGNANT
ENDOMETRIOMA
ENLARGED PCO
PAROVARIAN CYST
FOLLICULAR CYST
CORPUS LUTEUM CYST
THECA LUTEIN
TUBO OVARIAN ABSCESS

14. Benign ovarian Tumors FUNCTIONAL OVARIAN CYSTS BENIGN OVARIAN NEOPLASM
a. Follicular cysts
b. Corpus luteum cysts
c. Theca luten cysts
BENIGN OVARIAN NEOPLASM
1. Serous cystadenoma
2. Mucinous cystadenoma
3. Brener tumor
4. Dermoid cysts
5. Fibroma
6. Endometrioma

15. Functional cysts
These are cysts related to ovarian function i.e. the process of ovulation
By far the most common clinically detectable enlargements of the ovary in the reproductive years.
Can be reach up to 10 cm in diameter
All are benign and usually asymptomatic
Resolve spontaneously.

16. Functional cysts Follicular cysts Corpus luteum cysts
Theca lutein cysts

17. Follicular cysts
Cystic follicle is defined as Follicular cyst of diameter > 3cm
Most common functional cysts.
Rarely larger than 8cm.
Lined by granulosa cells
Found incidentally on pelvic examination
Usually resolve within 4 – 8 weeks with expectant management
May rupture or torse occasionally causing pain and peritoneal symptoms.
If ovulation does not occur, a clear fluid filled follicular cyst lined by granulosa cell may result.

18. Follicular cysts
Notice the smooth inner lining of this cyst, which is nothing more than a follicle which has gotten large but neither burst nor undergone atresia

19. Corpus luteal cyst Less common than follicular cyst.
May rupture leading to hemoperitoneum and requiring surgical management( more in patients taking anti coagulants or with bleeding diathesis)
Unruptured cysts may cause pain because of bleeding into enclosed ovarian cyst cavity.
When ovulation occurs , corpus luteum is formed that may become abnormally enlarged through internal hemorrhage or cyst formation
Variable delay in onset of menses and confusion regarding possibility of ectopic pregnancy: acute abdomen

20. Corpus luteal cyst Ovary with hemorrhagic corpus luteum cyst
Hemorrhagic corpus luteum with spider web like contents
Hemorrhagic cyst with blood clot.
Hemorrhagic cyst with unusual appearance simulating a neoplasm.

21. Theca lutein cysts Least common Usually bilateral
Result from overstimulation of the ovary by β- hCG
Do not commonly occur in normal pregnancy
Often associated with hydatidiform moles, choriocarcinoma, multiple gestations, use of clomiphene and GnRH analogues.
May be quite large (up to 30 cm) , multicystic, and regress spontaneously.

22. Theca lutein cysts
Sonogram from a patient with bilateral theca lutein cysts. The typical multilocular appearance is noted in the left ovary.

23. Management of functional cysts
Expectant
Watchful waiting for two or three cycles is appropriate.
Combined oral contraceptives appear to be of no benefit.
Should cysts persist, surgical management is often indicated.
Oral contraceptives for functional ovarian cysts (Review)
Cochrane Database of Systematic Reviews 2011

24. Benign ovarian neoplasm

25. Classification Neoplasms derived from the surface epithelium
• Neoplasms derived from germ cells
• Neoplasms derived from specialized gonadal stroma
• Neoplasms metaplastic to the ovary

26. Benign epithelial ovarian tumors
• 30% of epithelial ovarian tumors in postmenopausal women are malignant
• 7% of epithelial ovarian tumors in premenopausal women are malignant
Serrous cystadenoma
Mucinous cystadenoma
Brenner tumor

27. Borderline Epithelial Tumors
Atypical proliferating tumors
• Greater epithelial proliferation
• Noninvasive
• 15% of epithelial ovarian cancer
• Mean age at diagnosis: 40y
• Usually asymptomatic
• Can cause pain/pressure
• Diagnosed as ovarian mass/cyst
• CA-125 usually not elevated

28. Borderline Epithelial Tumors
Risk factors:
– Infertility
– Infertility drugs
– Hereditary?
• Protective:
– Multiple births
– Breast feeding
– Oral contraceptives

29. Borderline Epithelial Tumors
Treatment
– Surgery
• Cystectomy;USO – 12% recurrence (?)
• TAH + BSO – 2.5% recurrence (?)
• > 50% diagnosed at stage Ia
• Invasive / noninvasive implants:
Invasive implants are the most important predictor of recurrence
• Further therapy: not useful- Does not respond to chemotherapy
• 5 & 10-year survival > 90%, 20 year survival of 70%

30. Epithelial Ovarian Tumors - Serous Tumors
May occur on the ovarian surface, occasionally arises in extraovarian peritoneum
Unilocular or multilocular containing clear serous fluid
Endosalpingeal cell-type
60% BENIGN - bilaterality in 25%:Smooth glistening cyst wall, no epithelial thickening or papillae, single layer of columnar cells line cyst
15% BORDERLINE - bilaterality in 34%:Epithelial atypia in cyst lining, with stratification and formation of papillae; No stromal invasion
25% MALIGNANT - bilaterality in 67%: Epithelial atypia
often greater, complex architecture of papillae, multinodular.
Stromal invasion present

31. Serous cystadenoma Generally benign Bilateral – 10-25 %
Risk of malignancy : 5 – 15 % borderline malignant
20 -25% malignant
Size ranges from 5-40cm
GROSS : multilocular with papillary components.
MICRO : low columnar epithelium with cilia.
Characteristic psammoma bodies (end products of degeneration of papillary implants)are found.
Associated fibrosis may lead to “cystadenofibroma”

32. Epithelial Ovarian Tumors - Serous Tumors
Serous Cystadenoma

33. Serous cystadenoma
1. Benign epithelial tumors of the ovary can reach massive proportions. The serous cystadenoma seen here fills a surgical pan and dwarfs the 4 cm ruler
2.Here is a benign serous cystadenoma that demonstrates multiloculation. Note that the inner surface is, for the most part, smooth, with only a solitary papillation at the upper right.
3. Ultrasound imaging
4. Histopathological section: With few papillary projections from the surface

34. Bilateral cystadenoma
Epithelial Ovarian Tumors - Serous Tumors
Bilateral cystadenoma

35. Epithelial Ovarian Tumors - Mucinous Tumors
Mucinous tumors are much less likely to be bilateral and to be malignant than Serous tumors!
80% BENIGN - only 5% bilateral
10% BORDERLINE
10% MALIGNANT - only 20% bilateral
• Cystic, mucin producing , usually multilocular
• Mostly intestinal-type cell, can also resemble endocervical cells
• May reach enormous size
•• 5% Pseudomyxoma peritonei: peritoneal cavity becomes filled with gelatinous mucinous fluid (similar to cyst contents), which mats together the abdominal viscera; Rx is surgical, and repeated operations are required.

36. Mucinous cystadenoma Have tendency to become huge masses
Round to ovoid masses with smooth capsules that are usually translucent or bluish to whitish gray.
Interior divided by discrete septa into loculi containing clear , viscid fluid.
Epithelium – tall, pale staining, secretary with basal nuclei and goblet cells
5 – 10% are malignant

37. Benign Mucinous Tumor of Ovary
Epithelial Ovarian Tumors - Mucinous Tumors
Benign Mucinous Tumor of Ovary

38. Benign Mucinous Tumor of Ovary
Epithelial Ovarian Tumors - Mucinous Tumors
Benign Mucinous Tumor of Ovary

39. Mucinous cystadenoma 1.Cut open section of mucinous cystadenoma..
2. Histological section showing tall epithelial lining with pale staining nuclei at the basal pole.
3. Variable echogenicity in the contents of an adnexal multilocular cyst

40. Brenner tumor( Transitional cell )
Fibroepithelial tumors derived from the surface epithelium of the ovary which undergoes metaplasia to form urothelial-like components.
Mean age at presentation: 50 years
Rare- Constitute % of all ovarian neoplasms
Usually benign ; But scattered reports of malignant Brenner’s available
Solid , grossly identical to fibroma,
Unilateral- 7 % are bilateral, left side predominance
Endocrinologically inert, but could be ass. with virilization and
endometrial hyperplasia - PMB- In postmenopausal women
On microscopy – markedly hyperplastic fibromatous matrix interspersed with nests of epitheloid cells showing “coffee beans” pattern

41. Brenner tumor( Transitional cell )

42. Brenner tumor( Transitional cell )
Hyperplastic fibromatous matrix interspersed with nests of epitheloid cells
On high magnification, they exhibit characteristic coffee bean nuclei (clearly visible in image). On low magnification, they resemble urothelial cell nests.

43. Brenner tumor: “coffee beans”
Brenner tumor( Transitional cell )
Brenner tumor: “coffee beans”

44. Classification Neoplasms derived from the surface epithelium
• Neoplasms derived from germ cells
• Neoplasms derived from specialized gonadal stroma
• Neoplasms metaplastic to the ovary

45. Germ Cell Tumors
10-15 % of ovarian tumors are germ cells, 3% of them are malignant
Rapidly growing
Produce symptoms:
Abdominal pain
Distension
Torsion
Rupture
Pelvic pressure
Menstrual disorders
Virilism

46. Germ Cell Tumors Classification of germ cell neoplasms Teratoma
Mature cystic teratoma
Monodermal teratoma (e.g. struma ovarii)
Immature teratoma
Dysgerminoma
Yolk sac tumor (endodermal sinus tumor)
Embryonal carcinoma
Choriocarcinoma

47. Germ Cell Tumors- Teratoma
Mature cystic teratoma(Dermoid): - Benign neoplasm
Most common ovarian teratoma and most common ovarian germ cell tumor
Typically occurs during reproductive years
Cystic tumor with firm capsule, filled with sebaceous material and hair (occasionally teeth can be found)
Thickened area from which hair and teeth arise is called "Rokitansky's protuberance"
Composed of mature elements derived from all three germ layers (ectodermal elements such as skin, hair, sebaceous glands, and mature neural tissue predominate; cartilage, bone, respiratory and intestinal epithelium are common)

48. Germ Cell Tumors- Teratoma
Mature cystic teratoma(Dermoid):
Often bilateral (15 -25%)
Malignant change occurs in 1-3%. Usually of a squamous type.
Complications include torsion-(Risk of torsion is 15%), rupture, infection, hemolytic anemia
An ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remains

49. Dermoid Cyst Germ Cell Tumors- Teratoma mamillae or Rokitansky's
protuberances
Dermoid Cyst

50. Germ Cell Tumors- Teratoma
Dermoid Cyst

51. Dermoid Cyst Germ Cell Tumors- Teratoma
The photo below shows a well-developed tooth arising from the right side of the mural nodule ("Rokitansky nodule") that contains most of the solid teratomatous elements. The central portion of the nodule contains mostly cutaneous tissues (skin, sweat glands, and hair follicles), while the neural tissues extend into the wall toward the left.
Dermoid Cyst

52. Dermoid Cyst Germ Cell Tumors- Teratoma
1. Mature cystic teratoma with typical long hyperechogenic lines and bright prominent spots representing hair in fluid.
2. Mature cystic teratoma with Rokitansky nodule or 'dermoid plug'(arrow) with posterior acoustic shadowing.
Dermoid Cyst

53. Germ Cell Tumors- Teratoma
Monodermal teratoma
A teratoma composed predominantly of one tissue element
Most common type is "struma ovarii", which is mature thyroid tissue

54. Classification Neoplasms derived from the surface epithelium
• Neoplasms derived from germ cells
• Neoplasms derived from specialized gonadal stroma
• Neoplasms metaplastic to the ovary

55. Fibroma Most common benign, solid neoplasms of the ovary.
Compose approx 5% of benign ovarian neoplasms and 20% of all solid tumors of the ovary.
Frequently seen in middle-aged women.
Characterized by their firmness and resemblance to myomas
Misdiagnosed as exophytic fibroids or primary ovarian malignancy
Not hormonally active
Fibromas may be associated with ascites or hydrothorax as a result of increased capillary permeability thought to be a result of VEGF
Mieg’s syndrome (ovarian fibromas, ascites and hydrothorax) is uncommon and usually resolves after surgical excision.

56. Fibroma grayish white and firm Cut section
Microscopically – stellate or spindle shaped cells arranged in fusiform pattern. Hyalinisation is frequent. The elongated fibroblastic tumor cells have spindle-shaped nuclei and may contain small amounts of lipid in their cytoplasm 

57. Thecoma
Solid fibromatous lesions that show varying degrees of yellow or orange discoloration
Almost always confined to one ovary
Usually >40 years, 65% after menopause
May be hormonally active and hence associated with estrogenic or occasionally androgenic effects.
Rarely malignant

58. Gonadoblastomas
Gonadoblastoma is a rare benign tumor that has the potential for malignant transformation and affects a subset of patients with an intersex disorder or disorder of sex development (DSD).
Arise in patients with dysgenetic gonads - 46 XY f/b 45XO/ 46 XY mosaic.
Contain both germ cells and sex cord stromal cells.
Presents usually as phenotypic female <30 years with primary amenorrhea and virilization.
Treatment – laparoscopy or laparotomy with removal of b/l dysgenetic gonads.
Further treatment depends on malignant germ cell component
Contralateral ovary may harbour macroscopically undetectable gonadoblastoma.
Associated with dysgerminomas in 50%cases and with malignant germ cell tumours in an additional 10% cases.

59. Classification Neoplasms derived from the surface epithelium
• Neoplasms derived from germ cells
• Neoplasms derived from specialized gonadal stroma
• Neoplasms metaplastic to the ovary

60. Endometriomas Most common site of involvement is the ovary.
Large hemorrhagic cyst (chocolate cyst), Cyst walls are usually thick and fibrotic.
They may completely replace normal ovarian tissue.
USG: anechoic cysts to cysts with diffuse low-level echoes to solid-appearing masses.
They may be unilocular or multilocular with thin or thick septations
Malignant transformation: 0.3% to 0.8%
Management: medical and/ or surgical

61. Ovarian Endometriomas demonstrating hypoechoic cystic structures with low amplitude uniformly distributed echotexture in the cavity of the cyst.

62. Clinical presentation
Asymptomatic – accidentally discovered on USG
Chronic pattern of pain, increasing abdominal girth over months or weeks.
Associated with secondary symptoms of anorexia, nausea, vomiting, urinary frequency.
Could be associated with primary or secondary amenorrhea, menstrual irregularities, virilization, precocious puberty
Become acutely symptomatic if undergoes torsion, rupture or hemorrhage.
Benign ovarian neoplasms are indistinguishable clinically from malignant counterparts

63. Complications Torsion Intracystic hemorrhage Infection Rupture
Pseudomyxoma peritonei
Malignancy

64. Diagnostic evaluation of the patient with an adnexal mass
Complete physical examination
Pelvic ultrasound examination, Doppler?
Computed tomography scan with contrast enhancement
Tumor markers-( ca-125)
Laparoscopy, laparotomy

65. Evaluation Abdominal and vaginal examination Assess Laterality
Cystic Vs solid
Mobile Vs fixed
Smooth Vs irregular
Ascites
Cul-de-sac nodules

66. Clinical features of benign ovarian masses
 Unilateral
 Cystic
 Mobile
 No ascites
 No cul de-sac nodules
 Slow or no growth

67. TVS Pattern recognition is superior to all other scores.
Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol2008, RCOG 2011

68. TVS
The morphology index (MI) presently used in the University of Kentucky Ovarian Cancer Screening Trial was published initially by Ueland and colleagues and is illustrated in Figure Both morphologic complexity and tumor volume, as calculated by the prolate ellipsoid formula, were related directly to the risk of malignancy
Morphologic abnormalities were easy to categorize, and interobserver variation was minimal. Risk of malignancy varied from 0.3% in ovarian tumors with a MI of <5 to 84% in tumors with a MI >=8. Using a MI >=5 as indicative of malignancy, the following statistical parameters were observed: sensitivity 0.981, specificity 0.808, PPV 0.409, and NPV Therefore, morphologic indexing is a relatively accurate and cost-effective method to predict risk of malignancy in an ovarian tumor.

69. Doppler Evaluation
Hypoxic tissue in tumors recruit low-resistance, high-flow blood vessels
Role in evaluating ovarian mass is controversial – as the ranges of values of RI,PI between benign and malignant masses overlap. PI<1, RI<0.4
Adding Doppler does not seem to yield much improvement in the diagnostic precision, but increases the confidence with which a correct diagnosis of benignity or malignancy is made..

70. Other imaging modalities
CT, MRI, PET not recommended in the initial evaluation
CT scan: evaluating
LN involvement,
Omental mets, peritoneal deposits, hepatic mets,
Obstructive uropathy
Probable alternate primary site when cancer is suspected based upon TVS
MRI : differentiating non adnexal pelvic masses (like leiomyomata), expensive and inconvenient.
ACOG GUIDELINES 2007

71. Radiological features of benign ovarian masses
1. Unilocular
2. Smooth surface
3. No solid elements
4. No external or internal outgrowth
5. No ascites
6. Unilateral
7. Normal Doppler flow

72. Tumor markers
CA-125
HE4
BHCG
LDH
AFP

73. Calculation of RMI (Risk malignancy index):
RMI=MxUxCA-125

74. Calculation of RMI (Risk malignancy index):
It is an effective way of triaging patients into low , moderate, high risk for malignancy, according to which the referral to a higher centre and management protocol will differ.
It is recommended that a ‘risk of malignancy index’ should be used to select those women who require primary surgery in a cancer centre by a gynecological oncologist.
RCOG Guideline No. 34 October 2003

76. Operative intervention

77. Indications for surgery
Any solid ovarian lesion
Any ovarian lesion with papillary vegetation on the cyst wall
Any adnexal mass >10cm in diameter
Palpable adnexal mass in a premenarchal or postmenopausal women
Torsion or rupture suspected

78. Ovarian mass in childhood:
History and physical examination
Appr. Imaging studies
Simple cyst
- Observe and reassess
Solid or solid cystic
MRI and tumor markers
High suspicion
of malignancy
Low suspicion
of malignancy
Wenever possible conservative or minimally invasive surgery is preferred to preserve endocrine and reproductive function.
Laparotomy
laparoscopy
Frozen section
Malignant –
oophorectomy and staging
Benign - cystectomy

79. Complex, solid, suspicious
Ovarian mass in reproductive age group
<5 cms.
>/= 5 cms
USG
USG
cystic
Complex, solid, suspicious
observation
Persistence or progression
surgery

80. Asymptomatic simple cysts
<5cms
Likely physiological
(do not require follow up)
5-7 cms
Yearly USG
>7cm
Require further imaging/surgical intervention.
RCOG 2011

81. Cyst Aspiration
Diagnostic cytology has poor sensitivity to detect malignancy, ranging from 25% to 82%
Not therapeutic, even when a benign mass is aspirated
Approx. 25% of cysts will recur within 1 year
Aspiration of a malignant mass may induce spillage and seeding of cancer cells into the peritoneal cavity

82. Ovarian mass In Postmenopausal women

83. Ovarian mass In Postmenopausal women
Ovaries atrophic and shouldn’t be palpable on pelvic examination.
Presence of palpable ovary must alert the physician to the possibility of an underlying malignancy.
Incidence in asymptomatic post menopausal women –
1.5% by pelvic examination
3.3% to 14.5% by USG
Causes -10% functional
90% neoplastic (either benign or malignant)
Obstet gynecol survey, 2002

84. Ovarian mass In Postmenopausal women
Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. It is recommended that, in the presence of a normal serum CA125 levels, they be managed conservatively.
Aspiration is not recommended for the management of ovarian cysts in postmenopausal women.
It is recommended that a ‘risk of malignancy index’ should be used to select women for laparoscopic surgery, to be undertaken by a suitably qualified surgeon.
It is recommended that laparoscopic management of ovarian cysts in postmenopausal women should involve oophorectomy (usually bilateral) rather than cystectomy.

85. Operative intervention

86. Operative Modalities
Laparoscopy vs laparotomy – decision based on suspicion of malignancy and technical expertise
No RCTs comparing recurrence rates following laparoscopy or laparotomy.
The objective is to try cystectomy if possible.
Laparoscopic surgery for benign ovarian tumours is associated with less pain, shorter hospital stay, and fewer adverse events than with laparotomy.
Cochrane Database of Systematic Reviews 2009

87. Operative Modalities The standards for laparoscopy in benign tumours
Careful examination of the external surface of the tumour and sampling of the peritoneal cavity
Avoidance of any tumoral rupture
Protection of the ovarian tumour with an endoscopic bag before removal